Assessment of risk and prophylaxis for deep vein thrombosis and pulmonary embolism in medically ill patients during their early days of hospital stay at a tertiary care center in a developing country
Ambarish Pandey, Nivedita Patni, Mansher Singh, Randeep Guleria
Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
Aim: Deep vein thrombosis (DVT) and pulmonary thromboembolism (PE) are important causes of morbidity and mortality in medically ill patients. This study was done to assess risk factors and prophylaxis given for DVT and PE in newly admitted medically ill patients during the first two weeks of their hospital stay at a tertiary care center hospital in India.
Methods: All patients within one week of their admission in intensive care unit (ICU) and wards were enrolled in the study after an informed written consent. Patients who had DVT prophylaxis within the past month or any contraindications for DVT prophylaxis were excluded. A structured proforma was designed and effective risk stratification for DVT was done. Patients were followed for up to two weeks to record any changes in the risk categories and document any signs of PE or DVT if present. Any prophylaxis given for DVT or PE was noted.
Results: Seventy-five percent of patients had the highest risk for DVT and PE. Only 12.5% had DVT prophylaxis within the first two days of admission. Within two weeks of admission, 30.8% of patients were discharged, and 16.2% died. 72.6% of the patients still in the wards belonged to the highest risk category. Clinical signs and symptoms of DVT and PE were present in 25.8% and 9.8% of patients, respectively after the second week of admission. 86% of symptomatic patients belonged to the highest risk category initially and none of them received any prophylaxis. 21.6% of the highest risk category patients died within two weeks of their admission. A statistically significant correlation was found between mortality and risk score of the patients for DVT and between lack of prophylaxis and mortality (p < 0.05).
Conclusion: A significant risk for DVT and PE exists in medically ill patients, but only a small proportion of the patients are given prophylaxis. This study underlines the need to aggressively implement DVT risk stratification strategy in medical patients and provide prophylaxis unless contraindicated.
Keywords: deep venous thrombosis, pulmonary embolism, risk stratification, DVT prophylaxis
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important cause of morbidity and mortality in critically ill medical patients. Individual identification of suspected DVT and PE cases could be a difficult task and blanket prophylaxis of all admitted patients may not be cost-effective, especially in a developing country such as India. Thus primary prevention of VTE with risk assessment, stratification, and DVT prophylaxis in high-risk patients is the most rational means of reducing mortality and morbidity. In this study we have shown that a significant risk for DVT and PE exists in acutely ill medical patients admitted to wards and intensive care units, but only a small proportion of the patients are currently given prophylaxis or investigated. This may be responsible for the increased mortality and poor prognosis seen in the patients with highest risk for DVT and PE. This study underlines the need to aggressively implement DVT risk stratification strategy in medical patients and provide prophylaxis unless contraindicated.
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